For many transgender and gender non-conforming individuals, hormone therapy is one of the options explored to affirm a gender role that is comfortable for them. Hormone therapy is the use of endocrine agents to cause physical changes that are either “feminizing” or “masculinizing”. Although the therapy is described as “feminizing” or “masculinizing”, not everyone undergoes hormone therapy with a feminine/masculine binary goal.
Starting Hormone Therapy
Hormone therapy can be managed by a properly-trained primary care physician, nurse practitioner, or physician assistant. For most people, hormone therapy is begun only after an assessment by a mental health professional or qualified hormone therapy provider. Before deciding to undergo hormone therapy, it’s important to talk with your doctor about how hormone therapy may limit fertility.
Since each hormone therapy plan is individualized based on a person’s goals and medical needs, the effects and effectiveness can vary, but most physical changes occur over the course of two years, with full effects taking up to five years.
Once hormone therapy has been started, you’ll see your provider for regular visits, to monitor the hormone effectiveness and side effects. If you have an existing medical condition, your doctor may want to see you more frequently. To help manage identity or legal issues, you may want to ask your doctor for a note that states you are receiving medical care that includes feminizing/masculinizing hormone therapy.
Risks of Hormone Therapy
Every medical intervention has risks. According to the World Professional Association for Transgender Health (WPATH), the risks of adverse (or negative) reactions to hormone therapy can be hard to predict because treatments are so individualized, and because there are many factors that affect risk. Before starting hormone therapy, be sure to talk to your provider about your risks.
What to Expect with Hormone Therapy
Beginning the journey of hormone therapy is much like going through puberty again. Some of the changes your body goes through may seem to happen very fast, while others that you are excited to experience may seem to take a long time.
Masculinizing hormones consist of androgens, primarily testosterone, which suppresses the production of estrogen. They can be administered as an oral pill, injection, implant, patch, cream, or gel.
Many people are excited to discover that their voice begins to deepen within the first three months, although it can take up to two years to fully change. Some of the other effects to expect in as early as three to six months, with the changes continuing for up to two to five years, include:
- increased pore size, oiler skin and acne;
- new facial and body hair growth, thickening texture and darkening color;
- body fat redistribution, losing fat around the hips and thighs, while possibly gaining in the abdomen;
- increased muscle mass and strength; and
- clitoris enlargement and increased libido.
Anytime during the first year, and during the course of masculinizing hormone therapy, you may discover some scalp hair loss, receding hairline, or even male pattern baldness.
Within the first six months, vaginal atrophy may begin and menstrual periods may stop altogether. Reproductive decisions should be discussed with your therapy provider—options may include egg or embryo freezing prior to hormone therapy. However, pregnancy may still be possible and hormone therapy can affect a developing fetus. Those at risk of becoming pregnant should discuss birth control with their provider.
Feminizing hormones include estrogen, testosterone blockers, and sometimes progesterone. Hormone therapy may be administered as an oral pill, skin patch, or injection. In the first three to six months, with changes continuing for up to two to five years, you can expect:
- softening and decreased oiliness of the skin;
- decrease in testicular size;
- redistribution of body fat, gaining weight on the hips and thighs;
- breast enlargement; and
- decreased muscle mass and strength.
Within the first year, taking up to three years for the full effect, you may notice thinner facial and body hair, and slower growth. For those with male pattern baldness, hormones cannot cause hair regrowth, however hair loss should stop fairly quickly, within the first three months.
You may also experience a decreased libido and decreased spontaneous erections within the first three months, with less firm erections. You may notice that sex and orgasm feel different.
If you’re sexually active with a partner who may become pregnant, you should continue using birth control to prevent unplanned pregnancy. However, feminizing hormone therapy can reduce fertility, and the degree of reversibility is not known, so you should talk to your doctor about sperm preservation and banking options prior to hormone therapy.
Hormone Therapy & Surgery
Dr. Loren S. Schechter, Medical Director of the Center for Gender Confirmation Surgery at Weiss, is a world-renowned plastic surgeon specializing in gender confirmation surgery, a board member of The World Professional Association for Transgender Health (WPATH), and a co-author of The Standards of Care (WPATH, v7) which provides flexible guidelines for promoting safe care of transgender individuals, including hormone therapy and surgery.
Not every transgender and gender non-conforming person chooses surgery, but for those who do, there are some recommendations for hormone therapy prior to surgery. Hormones such as estrogen, progesterone, and testosterone should be discontinued two weeks prior to surgery, while spironolactone may be continued. If you are scheduled for surgery, you’ll have a conversation with your surgeon to review all pre-surgery instructions.
Because both feminizing and masculinizing hormones can redistribute the fat in the face, taking up to several years for the full effect, it is sometimes recommended to remain on hormones for two years prior to choosing facial feminization or other gender-confirming facial surgeries. Hormone therapy is not required prior to chest/breast top surgery. The following procedures have a recommendation of 12 continuous months of hormone therapy, as appropriate, prior to surgery.
- Oophorectomy (removal of the ovaries)
- Hysterectomy (removal of the uterus)
- Orchiectomy (removal of the testicles)
- Phalloplasty (surgical creation of a penis)
- Metoidioplasty (surgical creation of a penis from an enlarged clitoris)
- Vaginoplasty (construction or reconstruction of a vagina)
- Breast augmentation surgery (recommended to help obtain better aesthetic surgical results, as the hormones will maximize breast growth)
Each person is different—hormone therapy isn’t medically appropriate or doesn’t fit the gender goals for some individuals. Feel free to reach out to the program coordinator at the Center for Gender Confirmation Surgery at Weiss for more information on hormone therapy recommendations prior to surgery.
(Special note: Hormone therapy treatments for adolescents are different than those for adults; this article is focused on hormone therapy for adults. Health care needs are diverse; the options discussed in this article are based on the current best practice guidelines published by WPATH, and co-authored by Loren S. Schecter, MD, Medical Director for the Center for Gender Confirmation Surgery at Weiss. They are designed to be a framework of safe medical guidelines with flexible standards of care for individual needs.)